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Affidavit to Release Public Records

This form is to request L&I to release public records in the contractors registration section.



Form
F625-066-000


 
Autorización para Proveer Información de Reclamos

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.



Form
F101-010-999



Alt Language(s):
Inglés
 
Contractor Financial Information

Used by the contractor to request L&I to release assignment of account that they used instead of a surety bond.



Form
F625-061-000


 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.



Form
F247-003-000



Alt Language(s):
Español
 
Notice of Completion of Public Works Contract

This is the form used by public agencies to request L&I's approval to release retainage. All contractors are to be listed on the request form with their associated affidavit id number.  Notices received without affidavit id numbers or incomplete information will not be processed and will be returned to the awarding agency. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.



Form
F215-038-000


 
Notice of Completion of Public Works Contract

This is the form used by public agencies to request L&I's approval to release retainage. All contractors are to be listed on the request form with their associated affidavit id number.  Notices received without affidavit id numbers or incomplete information will not be processed and will be returned to the awarding agency. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.



Form
F215-038-000


 
Request for Archive Records - Contractor Registration

This form is to request L&I to release archive records in the contractors registration section.



Form
F625-094-000


 
Request for Claim Information

Used by workers, workers' representatives, employers or employers' representatives to request claim information from L&I.



Form
F101-010-111


 
Application for Group Membership & Authorization for Release of Insurance Data
Used by employers who want to join a retrospective rating group; also, to authorize Labor & Industries to release the employers' insurance data to the retrospective rating group they want to join.

Form
F250-016-000


 





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